Epistaxis is a common Emergency Department (ED) complaint with over 450,000 visits per year and a lifetime incidence of 60% (Gifford 2008, Pallin 2005). Posterior epistaxis is considerably less common than anterior epistaxis and represents about 5-10% of all presentations. Many patients with posterior epistaxis will be managed with a posterior pack and admitted for further monitoring. Traditional teaching argues that:

Patients with nasal packs should be given prophylactic antibiotics to prevent serious infectious complications.

Patients with posterior packs should be admitted to the ICU for cardiac monitoring as they are at risk for serious bradydysrhythmias.

Objective: To review the literature behind the traditional teaching and use the evidence to guide our management. In this post, we’ll take on the first dogmatic teaching of prophylactic antibiotics.

One important note, the literature base is scant on all topics regarding epistaxis. Randomized Double-Blind Control Trials (RDCT) are rare and study quality is overall very poor.

The concern is that patients with packing in place are at a high risk of developing infectious complications including acute otitis media (AOM), sinusitis and toxic shock syndrome (TSS). A deep dive into the archives resulted in four studies that look at the question (1 on posterior packs, 2 on anterior packs and one non-specified).

Population: RDCT of 20 patients with posterior packs (all packs were impregnated with antibiotics)Intervention: Intravenous cefazolinControl: Placebo (exact content not specifiec)Outcome: Neither group had any infectious complications. The packing in the placebo group was noted to be foul smelling and 8/10 had heavy growth of multiple organisms. In the cefazolin group, 8/10 packing had light growth of a single organism.

Population: Before and after, non-randomized, non-blinded study of 149 patients requiring packing for epistaxis.Intervention: Amoxicillin/Clavulanic Acid in first 78 patientsControl: No antibiotics in 71 patientsOutcome: Neither group had an infectious complication

Unlike the prior two studies, the Biswas and Biggs articles are more difficult to interpret due to their methodologies. In the Biswas study, 21 patients had anterior packing of which 9 received antibiotics. The investigators sent swabs from the packed and unpacked nares and found no difference in bacterial growth in the antibiotic and no antibiotic group.

In the Biggs study, 57 patients in total were enrolled in a before and after study. 38 were enrolled prior to the institution of an algorithm, which called for limited use of antibiotics. In the before group, > 70% of patients were given prophylactic antibiotics versus just 12% in the after group. Neither group had any infectious complications despite the change in antibiotic prescription rate.

Summary: Although the three identified studies are of varying quality and methods, overall it appears that administration of IV, oral or topical antibiotics was no different than placebo in terms of infectious outcomes. It is important to note that in all studies, packing was removed after 24-48 hours.

In the Derkay study, the presence of single organism growth in the antibiotic group raises the concern of selecting out resistant organisms. Additionally, antibiotics have a number of known nasty side effects including diarrhea (in up to 1 in 8 patients), allergic reactions and severe anaphylaxis (in up to 0.024%).

Bottom Line: The available evidence does not defend the routine use of prophylactic antibiotics in patients who require nasal packing for epistaxis. In patients with immunosuppression, they should be considered.

Imran – It’s a good question. We have no data to guide us here. It’s a risk benefit to be weighed. Yes, the brittle diabetic or elderly patient may be more likely to get an infection but they are also more likely to be on other medications that the antibiotics can interfere with and may be more at risk of complications. There’s no right answer here. I think that if the packing is coming out in 1-2 days, you’re fine not to provide the antibiotics regardless. Close follow up is a must regardless.

Hello,
Do you have any experience (or seen) tranexamic acid used intravenously for management of posterior epistaxis? There is a lot written about topical use in this setting but not much luck finding information on IV administration.

In this particular patient case this was a 91 year old female treated in emerg. tranexamic acid 1 gram IV. A-fib on warfarin. INR was 2.6.

Zan – I’ve used TXA topically for anterior bleeds quite a bit but haven’t for the posterior ones yet. There’s very little literature on TXA for epistaxis and I’ve seen nothing specifically on posterior bleeds. I would suggest writing your case up as it would add to the literature.

Hello Nadim,
I am not aware of literature on the disposable packs and antibiotics. The studies Swami reviewed had packing removed at 24 – 48 hours. So would need better evidence to see what would happen if packs stay in longer. My clinical practice would be, if the pack is going to stay in longer than 48 hours, we should consider prophylactic antibiotics, but this is not based on any evidence that I am aware of.

“seems to be a sig. PICO mismatch between your stated myth to bust and the actual articles

seems you are trying to knock down abx for post. packing in your post (which might very well be a myth)
and then you have 2 of the 3 articles primarily dealing with anterior packing

the one trial that did exclusively randomize patients with post packs used abx-impregnated gauze
i did not check but I would not be surprised if the other 2 trials did as well.”

Scott makes a number of important points in his post-publication peer review that we wanted to address. Firstly, thanks to Scott for reading the post and taking time to do post publication review.

My original intention was to take down two myths specifically about posterior packing. Unfortunately, the actual evidence was so scant that only 1 article could be found specifically looking at prophylactic antibiotics and posterior packs. We decided to, as best we could, address the issue including articles looking at both anterior and posterior packs. Unfortunately, we forgot to change this line in our final edits:

“1. Patients with posterior packs should be given prophylactic antibiotics to prevent serious infectious complications.”

The word posterior should have been omitted and changed to just “nasal.” We have updated this in the text.

Lastly, we wanted to address Scott’s point regarding antibiotic impregnated packing. The Derkay et al article clearly specifies that all packing was impregnated with antibiotics. The Pepper et al article doesn’t mention what packing was used and whether they were impregnated with antibiotics. The Biswas and Mal article specifically mentions using Rapid Rhino and Merocel which are not impregnated. Finally, the Biggs article was a mix of both impregnated and non-impregnated.

Hopefully, that clears up the issues from the post. Thanks again to Scott for a critical review. This is a great example of how post-publication peer review should work!

[…] TSS – An aside regarding TSS and antibiotic therapy in the setting of nasal packing: Case reports and case reviews regarding epistaxis management favor the lubrication of nasal tampons/gauze with antibiotic ointment, and the provision of systemic antibiotics post packing in order to prevent the occurrence of TSS secondary to S. aureaus infection. Several studies cite a reduction in nasal colonization by Staph species and decreased incidence of post-packing sinusitis when topical and systemic antibiotic therapy is utilized.2,21 As the literature regarding this topic is immense and not addressed entirely in this review; suffice it to say that the ACEP Clinical Practice Management Guide on Epistaxis recommends the application of topical antibiotic ointment, and the provision of systemic antibiotic therapy.2 This is a controversial practice; see here: http://rebelblog.wpengine.com/do-patients-with-epistaxis-managed-by-nasal-packing-require-prophylactic-antibiot&#8230; […]